Case report SPONTANEOUS DUAL RUPTURE OF GAS CONTAINING LIVER ABSCESSES IN A MALAYSIAN PATIENT Abdel Latif K Elnaim 1 *, Mohd Azim M Idris 1 and Mamoun Magzoub Mohamed 2 1. Department of surgery, National University of Malaysia Medical Centre Kuala Lumpur, Malaysia. 2. Department of Microbiology and Parasitology, Faculty of Medicine, University of Kassala, Kassala, Sudan. *Corresponding Author: Dr. Abdel Latif Khalifa Elnaim Department of surgery, National University of Malaysia Medical Centre, Kuala Lumpur, Malaysia. E-mail: almerfaby@gmail.com ABSTRACT Ruptured gas containing liver abscess is a rare condition with fairly high morbidity and mortality 1 . We report an even rarer case if not the first one. He presented in septic shock and underwent urgent laparotomy and drainage of the abscesses. After long ICU stay patient is currently well. Key words: gas containing, pyogenic, liver abscess, dual perforation. INTRODUCTION Gas containing pyogenic liver abscess is a rare disease with significant morbidity and mortality. The most common causative bacterium is Klebsiella pneumoniae followed by E. coli 1 .Gas formation results from mixed acid fermentation within the abscess cavity by formic hydrogenlyase, an enzyme that is produced by the causative bacteria with CO2 production in anaerobic medium 1 . Presenting features of pyogenic liver abscess include fever with chills, right hypochondrial or epigastric abdominal pain, anorexia and malaise 2 . When rupture occurs, the patient will present with picture of peritonitis including diffuse abdominal pain, jaundice and sometimes in septic shock 2 . Risk factors for pyogenic liver abscess include appendicitis, portal circulation septic thrombosis and biliary tract diseases. On investigating patients with pyogenic liver abscess, they will have raised WBC count and deranged liver functions. Blood culture will grow the bacteria in 50% of the cases, while pus culture will definitely reveal the causative bacteria 2 . Ultra-sound scan has 80-90% sensitivity in diagnosis of liver abscess while CT scan sensitivity is 95-100% 3 . Treatment for pyogenic liver abscess when diagnosed early is percutaneous drainage under U/S guidance with appropriate antibiotics 3 . However, when the abscess is ruptured and patient is in peritonitis, surgery is the choice 4 . CASE REPORT A 60 years old man with no known medical illness before, presented with eight days history of fever, upper abdominal pain, loss of appetite, loss of weight and infrequent vomiting. Patient was alert and conscious when arrived to emergency department and was able to walk although weak, but he suddenly collapsed there with severe drop in blood pressure (70/40), drop in oxygen saturation and he became tachycardic, tachypneoic and stuperosed. On physical examination, he was pale, dehydrated, and was febrile with temperature of 39.3 C. After resuscitation his BP became 100/58 and his heart rate was 116 B/M. On abdominal examination his abdomen was distended, tender with guarding which is maximal at epigastric and right hypochondrium. The liver was palpable 2 cm below the right costal margin and was tender. There were no other palpable masses, bowel sounds were sluggish. There were bilateral basal crepitations on both lungs with reduced air entry on the right side. His blood investigation showed Hb of 8.6 g/dl, WCC of 26.3x10 9 /L, CRP 27.58 mg/dl ,RBS was14.0 mmol/L, albumin was 30g/L, bilirubin was 10 umol/L, ALT was 224 U/L , ALP was 369 U/L, blood urea was 20 mmol/L and serum creatinine was 369 umol/L. Viral screening for hepatitis B and C was negative. Klebsiella pneumoniae was isolated from his blood before the operation, and the result was confirmed by